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Osha Complaint example Form: What You Should Know

Please be gentle and respectful of your potential employer's time  Please use the correct word size for the type of letter you want to provide. Use this template letter to provide your employer with the following information: If the employee's own personal protective equipment (PPE) is required, include the name, contact information, and telephone number of any qualified personnel that can provide instructions, advice, or instruction on proper maintenance. If the employee's workplace safety or health hazards are being ignored and/or a problem which requires action is not being addressed by the employer or the employer's authorized representative, state the nature of the hazard and the action that is required. Give the employer the name, contact information, phone number, and E-Mail address of the representative or employer's official representative you believe is responsible. Direct them to view the list of authorized representative or employer's official representative(s). Include names of other qualified persons responsible in this letter if they are present, Tell the employer whether they are aware of the following: The employee's condition(BS) and/or the nature  of the work is an undue and unreasonable risk to health or safety to that employee. For any violations of a safety or health Hazard, the employer can have a PSC  Complaint Filer Form Submit: 1. A cover letters. This cover letter should summarize your employee's situation and should have two or three key facts that show that the situation is a safety hazard or a hazard of undue risk to health. 2. An OSHA Complaint Form(s) (form, ,, ,, , or), form, ,, or . A copy of your OSHA Report on the Worker Accidents section of Occupational Safety and Health Survey of the U.S. Federal Government (OSHA Report)” (H-103), may also be helpful. 3. Any additional information or documentation that is likely to assist investigators and supervisors. 4. If you have additional information about OSHA or Federal regulations regarding the employee's situation be sure to explain.  For more assistance with this form please contact the PSC hotline at 800.424.9673.

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